Lake County

Public Health Assessment and Wellness

Community Resources for Mass Fatality Management

State: WA
Type: Model Practice
Year: 2013

ABSTRACT:

King County Washington is the 14th most populous county in the US, with 1.93 million people . It represents 28.6% of Washington State’s population, and includes Seattle, 38 other incorporated cities, and 19 school districts. It is home to the most diverse zip code and the most diverse school district in the nation, with twenty-three percent of residents speaking a language other than English and 19% born in another country. The two main targets for this practice are cities and healthcare (hospitals, long-term care and ambulatory care) facilities in King County. This target encompasses the whole of King County, as any King county resident or healthcare facility can be affected by a mass fatality incident.

There are many catastrophic incidents that could affect King County. The one most commonly referenced is a large earthquake, which could result in thousands of fatalities. In such an incident, the King County Medical Examiner’s Office (KCMEO) – part of Public Health – will not be able to take jurisdiction of fatalities quickly, so cities and healthcare facilities must be prepared to care for the decedents on their own for a period of time. This practice provides them with the necessary tools.

Goal: prepare cities and healthcare facilities to manage decedents when normal operations at KCMEO are expected to be suspended or impacted due to a high number of fatalities.

Objective 1: Prepare tools for use by healthcare facilities and cities.

After a mass fatality incident, the trauma of human remains not being treated with respect can affect the community. Images of decedents floating in the floodwaters after Hurricane Katrina have stuck in our collective consciousness and caused distress to those trying to move on from the tragedy. This practice’s tools help empower communities to take care of their decedents until KCMEO is able to take jurisdiction over the remains. While the practice will not be implemented immediately after an incident, it should reduce the time that human remains will be out in public.

ORGANIZATION:

Public Health - Seattle and King County

TITLE:

Community Resources for Mass Fatality Management

King County Washington is the 14th most populous county in the US, with 1.93 million people . It represents 28.6% of Washington State’s population, and includes Seattle, 38 other incorporated cities, and 19 school districts. It is home to the most diverse zip code and the most diverse school district in the nation, with twenty-three percent of residents speaking a language other than English and 19% born in another country. The two main targets for this practice are cities and healthcare (hospitals, long-term care and ambulatory care) facilities in King County. This target encompasses the whole of King County, as any King county resident or healthcare facility can be affected by a mass fatality incident.
There are many catastrophic incidents that could affect King County. The one most commonly referenced is a large earthquake, which could result in thousands of fatalities. In such an incident, the King County Medical Examiner’s Office (KCMEO) – part of Public Health – will not be able to take jurisdiction of fatalities quickly, so cities and healthcare facilities must be prepared to care for the decedents on their own for a period of time. This practice provides them with the necessary tools.
Goal: prepare cities and healthcare facilities to manage decedents when normal operations at KCMEO are expected to be suspended or impacted due to a high number of fatalities.
Objective 1: Prepare tools for use by healthcare facilities and cities.
Objective 2: Distribute and train healthcare facilities and cities on tools.
After a mass fatality incident, the trauma of human remains not being treated with respect can affect the community. Images of decedents floating in the floodwaters after Hurricane Katrina have stuck in our collective consciousness and caused distress to those trying to move on from the tragedy. This practice’s tools help empower communities to take care of their decedents until KCMEO is able to take jurisdiction over the remains. While the practice will not be implemented immediately after an incident, it should reduce the time that human remains will be out in public.
A major benefit of this practice is that the tools, including templates, forms and instructions, can be quickly and easily adapted for use by other local health jurisdictions. It should be especially helpful to those areas that are not served by large medical examiner offices. In a catastrophe they may be waiting a long time for outside assistance to arrive, and these tools will help them to keep the remains secure and treat them with dignity until they are able to be examined and identified. By providing the cities and healthcare facilities with these tools they can prepare ahead of time for what is likely to occur. KCMEO will know that decedents are being treated with respect and in a way that will allow the cause and manner of death, as well as the identity, of the decedent to be determined at a later date.
This practice was partially implemented in King County in 2008, when basic guidelines were developed by Public Health and NWHRN staff and shared with healthcare facilities. The additional tools and templates were created and shared during two trainings with healthcare organizations in 2011. In spring 2013, training will be held for long-term care facilities.
In the spring and summer of 2012, the practice expanded to the 39 cities in King County. Nearly 40 attendees participated in a briefing for cities on these tools in March 2012, and Public Health staff members are available to answer questions and assist with local implementation. Additionally, early discussions are underway to test cities’ ability to implement the tool in summer 2013 as part of a volunteer exercise.
The main costs have been staff time to research, write, share and incorporate feedback. As the tools themselves already exist, the main costs for other local health jurisdictions should be limited to minimal staff time to make adjustments to the practice, plus time to train any cities and healthcare facilities. This can be completed with one-day workshops including small table-top exercises to talk through the practice. From there, it would be up to the healthcare facilities and cities to incorporate the practice into their training and exercise plans. The objectives of the practice have been met, as has the overall goal.

ResponsivenessThe public health issue that this practice addresses This practice helps Public Health meet the CDC and ASPR Emergency Preparedness Capabilities for Fatality Management by addressing the gap between medical examiner office capability and the need that will be created when a catastrophic or even small but highly concentrated mass fatality event occurs. In all of 2010, KCMEO took jurisdiction over 2,163 deaths, and performed autopsies on 1,199 decedents (KCMEO 2010 Annual Report). This is an average of just under 100 autopsies per month, and is significantly fewer than the number of autopsies and examinations that would need to take place in a much shorter period of time should a catastrophic event take place. The Seattle fault scenario (https://www.eeri.org/wp-content/uploads/2011/05/seattscen_full_book.pdf) estimates the County could be facing upwards of 1,600 fatalities from a major earthquake and given that, it is clear that KCMEO would quickly become overwhelmed. While federal assistance would no doubt be available, it would take two or three days to arrive, and longer to set up a means to process and identify remains throughout the County. Cities, healthcare facilities, and the public would all demand action be taken to respectfully address the needs of the decedents and their families sooner than that.
This practice also addresses the issues raised by a sustained influenza pandemic. While initial deaths may be manageable by KCMEO, over time it will become too much for all jurisdictions to manage. In the city of Seattle alone, professionals estimate that flu similar to the 1918 pandemic would result in 11,000 fatalities (http://www.seattle.gov/emergency/hazards/disease.htm). As federal assistance will be extremely limited in such a far-reaching event hospitals, healthcare facilities, and members of the public will need to address the care of the dead in their communities. This practice helps them implement plans to do this.
The process used to determine the relevancy of the public health issue to the communityThis practice was seen as relevant to the public health and healthcare community on several fronts. The first is in response to requests from the community directly. City emergency managers had been asking for some more specific instruction on how to manage deaths. Two jurisdictions in particular – Mercer Island and Vashon Island – have been especially vocal, as the islands are likely to be cut off in an earthquake due to damage to transportation infrastructure. Meanwhile, hospitals and other healthcare facilities which already have limited morgue capacity during regular operations recognize that after a large incident, not only will people within their facilities die and need care, but people who are not sure what to do may bring decedents to the facilities for disposition. It is also relevant to the public directly, especially the component providing instructions for the management of decedents at home. The second is as a way to improve the County and healthcare’s Public Health Emergency Preparedness Capability and Healthcare Preparedness Capability for Fatality Management. It is especially helpful in meeting the obligations outlined in PHEP Function 5: Participate in fatality processing and storage operations.
How the practice address the issueThe practice addresses the issue in two parts: Guidelines for Healthcare Facilities and Guidance for Cities.
Guidelines for Healthcare Facilities: This component of the practice consists of the following documents:
Healthcare Mass Fatality Management Guidelines: This is an overview of common concepts and terms involved in the Medical Examiner’s Office, and it provides guidance on tracking of human remains, personal effects, care of human remains (including temporary morgue guidelines) and communication with families. It also includes recommended job functions for response staff.
Mass Fatality Response Plan Template: This provides healthcare facilities with suggested language to use in their internal plans.
Tabletop Exercise Template: This provides healthcare facilities with a way to test their plans.
Deaths Occurring in a Healthcare Facility: Algorithm explaining how deaths are processed.
Decedent Identification Tag
Decedent Information Form: Form to be completed to assist in identifying the decedents.
Personal Effects Tracking Form: Way for staff to ensure chain of custody and accounting for personal effects associated with human remains Guidance for Cities This component of the practice consists of the following documents:
Catastrophic Fatality Management:
Guidelines for Cities: This is an overview of common concepts and terms involved in the Medical Examiner’s Office, and it provides guidance on tracking of human remains, personal effects, care of human remains (including temporary morgue guidelines) and communication with families. It also includes recommended job functions for response staff.
City Remains Procedures: Algorithm explaining how to handle deaths in extraordinary circumstances
Deaths Occurring in a Healthcare Facility: Algorithm explaining how deaths are handled on a regular basis.
Decedent Identification Tag
Decedent Information Form: Form to be completed to assist in identifying the decedents.
Personal Effects Tracking Form and Instructions: Way for staff to ensure chain of custody and accounting for personal effects associated with human remains
Remains in Place Public Messaging: Condensed information on how people can manage deaths at home. This will be made available online in the event of a prolonged incident so citizens can access it directly.
InnovationThis practice is new to the field of public health?
The process used to determine that the practice is new to the field of public healthPublic Health and NWHRN staff members conducted an assessment to determine whether existing practices could be adapted to address this particular component of mass fatality response. While there are many mass fatality response tools and plans, none appear to address both specific needs directly. Federal plans, such as the Department of Health and Human Services’ Fatality Management Concept of Operations, outline the specifics of their response, which tends to revolve around the work of federal agencies and does not directly address the needs of the community to manage fatalities temporarily themselves. Other plans, such as WHO-sponsored “Management of Dead Bodies after Disasters,” provide guidance to first responders but not the public.
The assessment of local plans showed thorough concepts of operations but often had no answers to the questions of a medical examiner or coroner unable to retrieve remains from both healthcare facilities and non-healthcare locations. Some plans, such as the APC Mass Fatality Toolkit, provide great overall guidance but not enough for the two groups of local emergency managers and healthcare facilities. The levels of detail in such plans as the New York City Office of the Chief Medical Examiner and Virginia state plans do address the needs of the medical examiner or coroner’s office and healthcare facilities, but do not provide information for individual cities. Los Angeles County does have the “Guidance for Hospitals and Other Healthcare Entities,” but for reasons described below it was not seen as sufficient to address our identified need.
How this practice differs from other approaches used to address the public health issueThe primary document Public Health, KCMEO and NWHRN consulted is the “Guidance for Hospitals and Other Healthcare Entities” element of the Los Angeles County Mass Fatality plan. That attachment includes many great resources, including proposed timelines, job actions sheets, and equipment and supply lists. It does not, however, include tools such as easily replicable plan templates, identification tags and tabletop exercises for healthcare facilities, nor does it address concerns of cities within L.A. County.
Beyond the three plans mentioned previously we have not seen other approaches to this issue specifically. Our assessment identified plans, such as the Commonwealth of Massachusetts Mass Fatality Management Plan, that address the fact that medical examiners may be overwhelmed and need outside assistance, but we were not able to find other tools to use that help with the cities and the healthcare facilities while they wait for the remains to be collected or interred.
Facilities and cities needed instructions, guidance, job descriptions and other tools to address their needs before a medical examiner or coroner can be on the scene. This practice bridges that gap and fills that need.

Primary stakeholders The primary stakeholders are KCMEO, Public Health – Seattle and King County, the NWHRN, healthcare facilities throughout the county, and city emergency managers.
LHD's role Public Health was the lead on this practice, in conjunction with the KCMEO and the NWHRN. KCMEO is part of the Prevention Section of the Health Department, so preparing the Mass Fatality Management plan falls to Public Health. Over the course of seven months, a team of four, including a forensic anthropologist and three planners met every Friday to discuss planning components. Part of that time was spent on devising this practice. Outside of those meetings, the Public Health and NWHRN planners worked to revise and combine input to refine the tools. Initial drafts were shared with some city emergency managers and healthcare facility managers for early input to help ensure that the tools would be useful and easy to understand.
Once the practice was prepared, Public Health was responsible for training on the tools. This included two trainings for healthcare facilities, as well as a briefing for cities in March 2012. An additional training for long-term care facilities will be conducted in spring 2013. The base mass fatality management plan, which references this practice, is available online, and anyone interested in receiving it can request it.
Stakeholders/partnersKCMEO, Public Health and NWHRN staff members were intimately involved in preparing the documents. Hospitals and healthcare facilities involved in the NWHRN provided feedback on the healthcare guidelines, and both healthcare organizations and local emergency managers were given the opportunity to provide detailed feedback to the practice and raise concerns. Suggested edits were considered by the smaller team and revised documents were redistributed to the stakeholders. Going forward, Public Health and the NWHRN plan to work with partners to further test the implementation of the healthcare guidelines and city guidance, through table-top exercises and functional drills as resources become available.
Public Health has a very active presence in the community, and strong relationships with cities and healthcare organizations via the NWHRN. Through the NWHRN, Public Health staff support the goals of building and enhancing partnerships, allowing the healthcare community to make strategic unified decisions effectively. Staff members also advocate to emergency management partners on behalf of healthcare organizations. The work includes planning, training and exercises, resource and information sharing, and response. By using those existing relationships and processes, Public Health and NWHRN were able to easily share information and seek input to ensure the end result was usable and beneficial.
Public Health staff also work closely with emergency managers throughout King County, regularly briefing staff on health, medical and mortuary issues and meeting with them to address concerns.
Lessons learned One of the lessons learned was the need to provide evidence to some that the practice is indeed relevant to them. For example, some ambulatory care facilities initially did not believe the practice applied to them, since they do not normally handle human remains on site. By listening to their concerns and going into more detail about the practice and some of the possible realities of a large pandemic or earthquake, Public Health and NWHRN staff members were able to increase the participation of such facilities, raising their awareness of this potential concern.
Tasks Taken to Implement the PracticePreparing the tool: In order to put together both the healthcare and the city guidance, Public Health, NWHRN, and Medical Examiner staff met dozens of times. During these meetings, they outlined what information might be beneficial for healthcare facilities and cities, as well as what information would be needed by the medical examiner’s office in order to eventually determine cause and manner of death as well as the identity of decedents. Through multiple iterations, back and forth discussion, and research of applicable laws, drafts were prepared. These drafts were shared for feedback, which was then incorporated.
Distributing and training on the tool: An initial training took place in 2008. Two more trainings were held in 2011 and 2012, with another scheduled for 2013. Additionally, city emergency managers were invited to a March briefing to learn more about the plan that tools specifically. The basic Mass Fatality plan, including a list of attachments, is available online. Anyone interested in receiving this information, including those outside of King County, need only click on the ‘contact us’ link on the website to request the full set of tools.
Time frameThe healthcare guidelines were drafted in 2008. After additional funding was secured, a major revision began in December 2010 and completed in the summer of 2011. This revision included the addition of a plan template and sample tabletop exercise. Work on the City guidance began in spring 2011 and was completed in the summer of 2012.
ImplementationThe first step was to meet to discuss need for guidelines. This included both a revision to existing healthcare guidelines as well as the response to the request from city emergency managers for guidance for them. The planning team created a list of components for both the healthcare and city guidelines. This list grew as needed, with some items added after suggestions were made by external audiences. That list led the team members to research existing documents in other jurisdictions for additional information to include. Once the information was gathered, the team drafted documents.
The draft documents were reviewed internally repeatedly, with planning team members assigned specific areas to address and refine. Once the documents had been reviewed internally, they were shared externally and feedback was solicited. Once that feedback was received, further edits were made until as many questions as possible were addressed in the guidance. The final versions were then made available to all for use.
Lessons learned We were able to use the distribution of these tools as a test for a new means of sharing information and seeking feedback from our emergency management partners. While we have always sought feedback from our emergency management partners, this new method for tracking who received the item for review, as well as tracking their suggested comments, created a more efficient, streamlined process. Going forward we are using this new method for the sharing of other plans to ensure that we have a record of who has received the plan for review, as well as an electronic record of all suggested edits.
Cost of implementationTime for planners: $10,000Training costs: nominal printing fee

Objective 1: Prepare tools for use by healthcare facilities and cities. The measures used to evaluate meeting this objective from a process perspective include the time put into preparing the tools and whether the tools were made available for input by the primary users of the tool. The tools were discussed over thirty weeks of planning meetings. Planners conducted research prior to these meetings, drafted tools for review, and revised them based on the meetings. Hospitals, ambulatory care facilities and long-term care facilities were provided with the opportunity to weigh in on the healthcare guidelines in 2008, and those suggestions were incorporated into the 2011 revision. The cities that had expressed the most interest in catastrophic mass fatality response were also asked to provide input on the city guidelines during the drafting process.
The data to support the assessment of this process comes from calendar records of meetings with the planning team and healthcare providers, and email records of the requests made to city emergency managers to provide input on the draft guidance. Through the collaborative process of internal and external meetings used to construct the tools, as well as the requests for feedback, Public Health, NWHRN and KCMEO staff members were able to increase their knowledge of the needs of the healthcare community and city emergency managers.
Public Health, NWHRN, and KCMEO team members received the feedback from healthcare partners and city emergency managers. That information was listed on a work plan kept updated by the project manager. As the revision process continued, the team members were able to ensure that all of the points raised were addressed in so far as the requested edits made sense for and would be of value to the end users of the tools.
Objective 2: Distribute and train healthcare facilities and cities on tools. The measures used to evaluate meeting this objective from a process perspective include the distribution of the guidance to all healthcare facilities and cities and attendance at trainings. The measures used to evaluate meeting this objective from an outcomes perspective include the feedback received at trainings and the interest and willingness of partners to incorporate these guidelines into their plans.
The data to support the assessment of the process and outcomes is found in multiple places. The attendance sheets for trainings demonstrate the breadth of interest in receiving information on this document. Evaluations completed at the end of trainings provide information on how engaged these partners feel and how useful they find the tools. Additionally, distribution can be measured by the email lists used by the NWHRN and Public Health staff to send out the final versions of these tools.
Public Health and the NWHRN learned that templates were the most useful items to provide, and that, especially for the healthcare facilities, the trainings helped them to understand the issue and how the tools address it. At the July 2011 training, which included representatives from hospitals, long-term care facilities and ambulatory care facilities, nearly 80% of the attendees completed an evaluation. One hundred percent of them agreed or strongly agreed that the workshop facilitated the sharing of a best practice in mass fatality management and that it helped them identify gaps in their current planning. Additionally, all agreed or strongly agreed that the training was helpful to their organization. When asked what they found useful about the event, responses included: “The template - thank you for putting it on a CD!”; “Made me realize gaps in our preparedness;” and “Good information.” When asked what would improve the training for next time, one attendee stated “Need more people to attend!”; outlining their recognition of the importance of these tools.
At the ambulatory care facility training in February 2012, over 85% of attendees completed an evaluation. They were unanimous in strongly agreeing that the training provided technical assistance regarding mass fatality planning. When asked what they found useful about the event, one respondent commented: “All the information was great. The template is amazing.” Team members from Public Health, the NWHRN and KCMEO received the evaluation results and are using the suggestions to adjust slightly the training scheduled for 2013.

Stakeholder CommitmentThe benefit of this practice is that the tools are mostly self-explanatory, which will allow facilities to incorporate the tools into their internal response plans without using significant staff time or organization resources. While trainings were initially necessary, the information is available for healthcare organizations and jurisdictions to use as they see fit. The main sustainable aspect is keeping the tools available online, and having contact staff at Public Health and the NWHRN available to answer questions from those new to implementing the tools. The planning team is committed to ensuring that they are available to respond to questions and requests, but they also anticipate that such requests should be minimal.
These tools support KCMEO and Public Health by increasing preparedness in the community. As such, there is departmental support for ensuring that this heightened preparedness level is sustained. It makes strong fiscal sense to continue supporting the implementation of these tools as the return in an emergency is large.
SustainabilityThe practice will be sustained over time through incorporation of the component into future exercises and the availability of the tools. Currently, many cities in the County are already working to incorporate components of the tool into their comprehensive emergency management plan, and hospital emergency managers are using the information to update their own internal response plans. Additionally, at least one city – Mercer Island – has expressed strong interest in testing these tools in a functional exercise in 2013. Public Health will work to include various components of these tools in future drills as well to ensure that they are reviewed on a regular basis.